Disparities in Quality of Life by Appalachian-Designation Among Women with Breast Cancer

Introduction Few studies have examined the association of geography and quality of life (QOL) among breast cancer patients, particularly differences between Appalachian and non-Appalachian Kentucky women, which is important given the cancer and socioeconomic disparities present in Appalachia. Purpose The purpose of this study was to determine whether women with breast cancer residing in Appalachian Kentucky experience poorer health outcomes in regards to depression, stress, QOL, and spiritual wellbeing, relative to those living in non-Appalachian Kentucky after adjusting for demographic, socioeconomic, and health-related factors. Methods Women, aged 18–79, recruited from the Kentucky Cancer Registry between 2009 and 2013 with an incident, primary breast cancer diagnosis completed a telephone interview within 12 months of diagnosis. In this cross-sectional study, sociodemographic characteristics and mental and physical health status were assessed, including number of comorbid conditions, symptoms of depression and stress, and QOL. Results Among 1245 women with breast cancer, 334 lived in Appalachia and 911 in non-Appalachian counties of Kentucky. Appalachian breast cancer patients differed from non-Appalachian patients on race, education, income, health insurance status, rurality, smoking, and stage at diagnosis. In unadjusted analysis, Appalachian residence was associated with having significantly more comorbid conditions, more symptoms of stress in the past month, and lower Functional Assessment of Cancer Therapy-Breast scores compared to non-Appalachian residence. Implications However, adjustment for sociodemographic and health-related differences by region appear to explain geographic differences in these poorer QOL indicators for women living in Appalachian Kentucky relative to non-Appalachian Kentucky. Policy-, provider-, and individual-level implications are discussed.


INTRODUCTION
entucky's national ranking as first in cancer incidence and mortality 1 is attributed primarily to health and socioeconomic disparities in the 54-county, rural Appalachian region of the state where residents carry a disproportionate burden of many preventable and screenable cancers. 2,3 When examining breast cancer, women in Appalachian Kentucky experience lower fiveyear (2011-2015) incidence rates than their non-Appalachian counterparts (117.2 vs. 128.6) and elevated mortality rates (23.9 vs. 20.7). 4 Further, women in Appalachian Kentucky are diagnosed with breast cancer at later stages (i.e., regional and distant) than women living in non-Appalachia (42.7 vs. 42.5, respectively). 4 Although regional variations in access to screening and diagnostic services 5 as well as cultural beliefs (e.g., fatalism) may explain these geographical differences in disease presentation, 6 this rural region is also impacted by increased socioeconomic deprivation; lower rates of educational achievement; geographic isolation; increased rates of at-risk health behaviors (e.g., smoking) and comorbidities; and limited access to primary care, mental health, and oncology specialists. 2 These circumstances and environment may lead to increased stress, worry, and decreased quality of life (QOL), particularly following a diagnosis of breast cancer. 7 When examining breast cancer-related QOL exclusively among rural communities, studies have found patients report high levels of stress and hopelessness, lower QOL and lower functional wellbeing, and increased symptom complaints. 8,9 Although these studies have been useful in determining an association between rurality and QOL among breast cancer patients, none have looked specifically at Appalachian Kentucky. Therefore, the purpose of this study was to determine whether women with breast cancer residing in Appalachian Kentucky experience poorer health outcomes in regards to depression, stress, QOL, and spiritual wellbeing relative to those living in non-Appalachian Kentucky after adjusting for demographic, socioeconomic, and health-related factors.  (4) additionally adjusting for current smoking and education.

K
ANOVA analyses were used to compare outcomes for Appalachian (exposed) versus non-Appalachian (non-exposed) residence; adjustments for covariates were made using ANCOVA. These analyses were performed separately for the dependent variables of number of covariates, total FACT-B score, and FACIT-Sp.
A similar analysis was performed using MANOVA without adjustments and MANCOVA with adjustments for dependent variables for stress and depression as well as for the domains of the FACT-B score because these outcomes were correlated. For models using each outcome variable, the t-statistic, df, and pvalue for the effect of Appalachian residence is provided. Analyses were completed in 2016 using in SAS® Version 9.3 (Cary NC); p-values ≤ 0.05 were considered statistically significant. While no regional differences in the age of diagnosis were identified, age was included as a covariate in subsequent models because age was associated with several of the QOL outcomes.

RESULTS
Appalachian women reported more physical comorbidities, higher stress levels at diagnosis and within the past month, and a lower FACT-B total score (and lower individual domain scores) indicating decreased QOL as compared to non-Appalachian patients (

IMPLICATIONS
To our knowledge, this is one of the first studies to specifically explore cancerrelated QOL differences between women with breast cancer residing in Appalachian versus non-Appalachian Kentucky. We found that Appalachian women were more likely to live in extremely rural communities, be of lower socioeconomic status (SES), and experience poor health outcomes such as higher rates of smoking, Stage 4 disease, physical comorbidities, and stress compared to their non-Appalachian counterparts. In reviewing the unadjusted mean scores, Appalachian women also had lower FACT-B total scores (2.55-point difference). However, after adjustment for sociodemographic and cancer attributes, women living in Appalachian Kentucky did not have poorer cancerrelated QOL compared to women residing in non-Appalachia. Adjustment for age at diagnosis, rurality, race, stage, income, and insurance status appear to mediate or explain regional differences in cancer-related QOL noted in the unadjusted comparisons. Specifically, income and private insurance are likely the important mediators explaining Appalachian regional differences in cancerrelated QOL because their addition to models resulted in no observed regional differences in the noted outcomes. These findings support Schootman et al. who found geographic differences in rates of depression and social support were not significant once SES, access to medical care, or other chronic conditions were included in the analysis. 11 Clinical and social support networks that address differences in mental and physical health trajectories may reduce regional differences in cancer-related QOL.
Although this study is a unique contribution to the breast cancer QOL literature, particularly its focus on Appalachia, there are noted limitations in the cross-sectional methodology. A primary limitation is collecting several of the sociodemographic variables and defining QOL based on women's self-report, which may be biased; yet women are the ultimate authority on their own QOL and mental health. Those completing interviews (38% of women we were able to contact) may differ from those who did not participate on attributes we could and could not measure. For example, KCR did not provide specific data on stage or age for those women who did not complete the survey. We were able to document that Appalachian women were more likely to agree to be interviewed than those living in non-Appalachia; however, this modest difference is unlikely to bias the consistently null findings observed here. Literature comparisons were generated from U.S. rural versus urban cancer QOL studies, which may not translate directly to Appalachian and non-Appalachian areas of Kentucky. Study limitations are countered with strengths, including use of the same interview protocol for all participants and use of outcome measures with strong psychometric properties, thereby limiting measurement bias. Sampling from KCR improved study power and sample representativeness.
Moreover, the study provides a foundation for future research examining psychological and other predictors of breast cancer-related QOL outcomes in Kentucky as well as the entire 13-state Appalachian region, including assessments of rural and urban counties, Appalachian subregions, and non-Appalachian areas.

SUMMARY BOX
What is already known about this topic? Rural-residing breast cancer patients have previously reported higher levels of stress and hopelessness, lower quality of life (QOL) and lower functional wellbeing, and increased symptom complaints.

What is added by this report?
Few studies have specifically examined differences in QOL between Appalachian and non-Appalachian Kentucky women diagnosed with breast cancer. Adjustment for sociodemographic and health-related outcomes by geographic region appear to explain differences in poorer QOL indicators for women in Appalachian Kentucky relative to non-Appalachian Kentucky.
What are the implications for public health practice, policy, and research? Socioeconomic status (SES) is a powerful influence on breast cancer outcomes, including QOL.